Tuesday, June 21, 2011

Unhinged in The New York Review of Books

The July 14, 2011 issue of The New York Review of Books includes the second of a two-part review of several new books on the topic of psychiatry, including my book Unhinged. Review author Marcia Angell, Senior Lecturer in Social Medicine at Harvard Medical School and former Editor in Chief of The New England Journal of Medicine, calls Unhinged “absorbing” in her article “The Illusions of Psychiatry,” where she also explores Irving Kirsch’s The Emperor’s New Drugs, Robert Whitaker’s Anatomy of an Epidemic, and the DSM-5.
Read the review here: www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry

7 comments:

It seems to me that Angell's two articles casts the psychiatric profession as a colossal scam. It strongly suggests that mental illnesses are a sham. Seems to be taking a cue from Thomas Szasz. I would like to think that my unbearable illness is not just some artifact of the pharmaceutical industry. But that seems to be the take of her articles.

His work consists of asking patients a series of questions about their symptoms to see whether they match up with any of the disorders in the DSM. This matching exercise, he writes, provides “the illusion that we understand our patients when all we are doing is assigning them labels.” Often patients meet criteria for more than one diagnosis, because there is overlap in symptoms. For example, difficulty concentrating is a criterion for more than one disorder. One of Carlat’s patients ended up with seven separate diagnoses. “We target discrete symptoms with treatments, and other drugs are piled on top to treat side effects.” A typical patient, he says, might be taking Celexa for depression, Ativan for anxiety, Ambien for insomnia, Provigil for fatigue (a side effect of Celexa), and Viagra for impotence (another side effect of Celexa).

As for the medications themselves, Carlat....doesn’t believe there is much basis for choosing among them. “To a remarkable degree, our choice of medications is subjective, even random. Perhaps your psychiatrist is in a Lexapro mood this morning, because he was just visited by an attractive Lexapro drug rep.”

Dr. Carlat, given the above, what is it you're recommending in your paid newsletter? How can you possibly promulgate polypharmacy of arbitrarily chosen drugs? Have you no concern for those masked side effects? Are you damaging as many patients as you're helping?

What is Marcia Angell smoking? She tells us that defining psychiatric illness is a politcal rather than scientific process; that psychiatric diagnoses are meaningless labels arrived at by consensus and not actual diseases. Then, two paragraphs later, she tells us that off-label psychiatric prescribing should be illegal because these drugs are designed to treat specific diseases in specific populations. Am I the only one who sees the contradiction?

@Mark,she is smoking the hard truth. She is pointing to the infinitely expandable world of mental disorder as currently defined (and subject to almost immediate revision) where MD's with the not so subtle assistance of the pharmaceutical industry can put down their copy of DSM-1...infinity and dish out whatever tickles their fancy to treat what is almost inevitably destined to become tomorrow's dramatic new condition. Given the lobbying power of big pharma I wouldn't lose any sleep over the possibility of the FDA's taking things in hand and forbidding the off-label use of psychotropic medications.

American 'medicine' is an international disgrace at this point - 33rd, give or take, in the WHO indicators sweeps and we spend better than twice what any other country spends on health - today's Boston Globe featured both the Beiderman slap on the wrist and the disgraceful hip fracture study. Not to mention the cost of Roche's moaning and shameful conduct over Avastin at the taxpayer supported reconsideration panel.

The problem in psychiatry is not that the ilnesses presnted are nt real or that available medications are not a blessing. The problems are the sweeping statements from the different factions in psychiatry who have their different agendas.The patients who present to us in spite of the stigma are in distress and deserve good and approprate diagnosis and treatment.There is nowhere that states an initial evaluation should take 30 minutes or less or follow up should be 15 minutes.This is psychiatrists rewriting the medical standards to correct the ills of manged care.Patients need to know what kind of information any physician is required to obtain from them in order to make accurate dignosis and consequently good chance of approprate treatmnent. . Psychiatrist have to come to terms that many of their patients would have counsellors and have to learn how to work with this. Pharmacotherapy or medication management is not the same as dispensing meds -education of patient and family about illness and medication on an ongoing basis and monitoring of stressors are all important part of medication management. Patients need to know their rights- the right to accurate assessment. This is what needs to be stressed, not leaving the impression that their ilnesses are being minimized.

I loved "Unhinged". It is a great book. Iatrogenia... Have you read the whole book or only extracts of it? Dr. Carlat himself would tell you "fragmentation" can be a real problem. He is far from "promulgating polypharmacy of arbitrarily chosen drugs". Please, read the book first. The only thing I did not agree with is taking Med School out of the picture... many of us made the decision to become psychiatrists during the senior year. And at the very least, the training allows you to develop complex problem solving capacities… Is there anything more perplexing than the human brain and behavior? Illness is war and knowledge is the arsenal. You need to understand 2 + 2 = 4 before adventuring into fractions and algebra. I've heard physicians in other fields complain of the same... not using half of what they learned in Medical School (psychiatry, dermatology, genetics, ophthalmology, embryology, orthopedics…) Although I see the point… After all, books ARE getting thicker by the minute! On these grounds I will refuse to continue to read anything that refers to psychoneuroendocrinology, psychoneuroimmunology, chronobiology, genetics and others, any longer! Am I going to benefit (or my patients) from it?? If not, please leave it out of the book and if I am, then I am glad I went to Medical School. Congrats on the book and I love your blog as well… :)